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Headaches

1. Tension-type headaches

Very common. Often bifrontal pain. They are episodic,
occurring with variable frequency. Th e pain is described as pressure
or tightness around the head like a tightening band. Other than the headache
there are no other features (e.g. no photophobia). Th e headaches last no
more than a few hours and are not severely disabling. However, in rare cases
they may occur almost daily, in which case they become disabling. Stress and
fatigue are well-known trigger factors.

2. Migraine

Common, although not as common as tension headaches, and twice
as common in women than men. Migraines are stereotyped, i.e. attacks exhibit
the same pattern of symptoms and become recognizable to patients. Th ey
are typically unilateral (migraine is a corruption of the Latin (he)mi-cranium).
Associated with an aura in about a third of suff erers (migraine with aura
or classical migraine, as opposed to migraine without aura or common
migraine). Th e pain is described as throbbing or pulsatile. Th ere is sensitivity
to light, sound, and even smell, and nausea can also be a feature. Migraines last
between 4 and 72 hours, unless successfully treated. Some patients suff er from
aura without migraine. Such attacks are in the diff erential for TIAs (particularly
in older patients) and epilepsy.

3. Sinusitis

Patients usually report facial pain coming on over hours to days in
conjunction with coryzal symptoms. Th e pain is tight, as in tension headaches,
and is often exacerbated by movement. Th e headaches last several days, with
a time course consistent with the infection. Th e headaches are moderately
severe but not disabling. However, patients with chronic sinusitis may fi nd the
headaches frequent enough to interfere with their daily activities.

4. Medication overuse

Surprisingly common, particularly in women (about
fi ve-fold the incidence in men). Th is is seen particularly with migraine medications
and analgesics. Th e headaches experienced resemble either migraine
or tension-type headaches. Most patients will be taking very large quantities
of medication (on average 35 doses of six diff erent agents a week). It is often
diffi cult for patients to accept that the over-treatment of headache is actually
the cause of their ongoing headaches. Treatment consists of withdrawal from
analgesic use, which often results in a period of exacerbation before improvement
occurs.

5. TMJ syndrome

Most common in individuals aged 20–40, and four times
more prevalent in women. As well as headache, patients get a dull ache in the
muscles of mastication that may radiate to the jaw and/or ear. Patients also
often report hearing a ‘click’ or grinding noise when they move their jaw.

6. Trigeminal neuralgia

A rare condition, occurring more often in women,
with a typical age of onset around 60–70 years. Patients complain of unilateral
facial pain involving one or more of the divisions of the trigeminal nerve.
Th e pain lasts only seconds, and can be triggered by eating, laughing, talking
or touching the aff ected area. Although attacks last seconds, there may be
several or even hundreds a day and patients can develop a longer-lasting background
pain. Patients often avoid known triggers like shaving. Interestingly,
attacks rarely occur during sleep, unlike migraine or cluster headaches.

7. Cluster headache

Predominantly affects men. Th e headaches occur in ‘clusters’
for about 6–12 weeks every 1–2 years, hence the name. Attacks tend to
occur at exactly the same time every day or night, like an alarm clock going
off . Th e pain is focused over one eye. Th e pain is intense and causes the patient
to wake up and can be so severe that suicide is contemplated, until the pain
diminishes, around 20–30 minutes later. Th ey will probably have a red, watery
eye, rhinorrhoea, and Horner’s syndrome, suggested by a history of ptosis.
These headaches are very disabling.